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Do You Need Antibiotics Before Your Dental Visit?

Antibiotics treat bacterial infections. Antibiotic prophylaxis (AP) is the taking of antibiotics before a surgery or other procedure that may release large numbers of bacteria into your bloodstream (bacteremia) to decrease the chance of infection in another part of your body. During dental procedures that may cause bleeding, such as tooth extractions, large numbers of bacteria from the mouth can enter the bloodstream. In persons at “high risk” of infection or with certain heart conditions, there is concern that these bacteria may cause infection in other parts of the body (e.g. heart, prosthetic joints like a hip or knee). The immune system normally kills these bacteria, but antibiotic prophylaxis may offer these people extra protection. The American Heart Association (AHA) recommends that antibiotics be used prior to some dental procedures for persons with certain heart conditions, who may be at risk for developing an infection of the heart.

Numerous studies have pointed out that blood bacteria (bacteremia) may occur during normal daily activities, such as chewing, tooth brushing and flossing. It is likely that these daily activities induce many more bacteremias than typical dental procedures. While studies do show a strong association between certain dental procedures and bacteremia, they don’t show good evidence that there is a direct link between dental procedure associated bacteremia and infections in the heart or prosthetic joints.

In the past, antibiotics were recommended more freely, but the rules have changed in recent years. Here’s why. Antibiotics should only be used when the potential benefits outweigh the risks of taking them. Studies have not found good evidence that infections of concern are common after dental procedures, other than for people who are already at heightened risk, nor that antibiotic prophylaxis is necessary for most people. There can be considerable side effects from antibiotics including upset stomach, diarrhea and, more importantly, allergic reactions, some of which can be life-threatening. In addition, there is a growing problem in the United States and throughout the world in Infections from bacteria that are resistant to common antibiotics. Bacteria develop resistance to common antibiotics when they are prescribed too often or inappropriately. Therefore, it is important to use antibiotic prophylaxis only in the right situations and with those people most at risk for infection.

Here’s what the experts say.

Heart problems that don’t call for the use of antibiotics in dental procedures

For years, the AHA recommended that people with most heart problems, including murmurs, take a short-term course of antibiotics before visiting the dentist. The goal was to reduce the risk for infective endocarditis, an infection of the heart’s lining or valves that could be caused by oral bacteria. However, those at risk are exposed to oral bacteria on a daily basis during brushing and flossing and do not develop infective endocarditis. Also, research has shown that antibiotics offer little protection against infective endocarditis for most people. Therefore, the AHA guidelines have significantly reduced the number of individuals and procedures where AP is recommended.

Heart problems that call for antibiotics in dental procedures

Virtually all guideline committees around the world recommend antibiotic prophylaxis for those individuals at high risk of an adverse outcome from infective endocarditis and who are undergoing invasive dental procedures. Today, the AHA only recommends antibiotics before dental procedures for patients with the highest risk of infection, those who have:

A prosthetic heart valve or who have had a heart valve repaired with prosthetic material

A history of endocarditis

A heart transplant with abnormal heart valve function

Certain congenital heart defects including:

Cyanotic congenital heart disease (birth defects with oxygen levels lower than normal), which has not been fully repaired, including in children who have had surgical shunts and conduits

A congenital heart defect that has been completely repaired with prosthetic material or a device for the first six months after the repair procedure

If you’re not sure about the guidelines for your heart condition, check with your heart specialist. If you have one of these conditions, always tell your dentist. Also, alert your dentist if - you (or your child) are allergic to any antibiotics or other medications.

Antibiotic prophylaxis and joint surgery

In the past, people who have had a joint replacement, such as a hip or a knee replacement, were often prescribed antibiotic prophylaxis before invasive dental procedures. While this still may be necessary for some individuals, in general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended routinely prior to dental procedures to prevent prosthetic joint infection.

Based on careful review of the scientific literature, the American Dental Association found that dental procedures are not associated with prosthetic joint implant infections, and that antibiotics given before dental procedures do not prevent such infections. The American Dental Association has found it is no longer necessary for most dental patients with orthopedic implants to have antibiotic prophylaxis to prevent infection.

A joint expert group of the American Dental Association and the American Academy of Orthopaedic Surgeons found moderate strength evidence that dental procedures are unrelated to implant infection and that antibiotic prophylaxis prior to dental procedures does not reduce the risk of subsequent implant infection. The group stated that practitioners might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.

If you have any questions about your situation, particularly if you have a significant immunodeficiency or an already infected prosthetic joint, make sure to discuss your situation with your dentist and orthopedic surgeon or physician to determine the need for appropriate prophylaxis.

Other uses for antibiotics in dentistry

If your dentist detects signs of an acute or chronic infection in your mouth, particularly when accompanied by fever, swelling or other signs, you may be prescribed antibiotics. Tooth infections occur when bacteria enter a tooth’s root, causing pain, tissue death and buildup of pus. Called an abscess or abscessed tooth, this kind of infection can spread to other areas of the head. Treatments for abscesses can include antibiotics, root canals and tooth extractions. Periodontal disease can also lead to serious gum abscesses.

Antibiotic prophylaxis before typical periodontal, third molar or other surgeries is usually not necessary. Depending on your personal medical history, however, you may still be a candidate for premedication. For example, antibiotic prophylaxis might be useful for patients undergoing invasive dental procedures, who also have compromised immune systems, due to, for instance, diabetes, rheumatoid arthritis, cancer, chemotherapy and chronic steroid use.

Finally, always provide your dentist or physician with a complete medical history and discuss whether antibiotic prophylaxis before dental treatment is right for you. Also, remember that brushing, flossing, good diet and visiting your dentist regularly help maintain good oral health, prevent tooth and gum infections, and avert the need for more aggressive dental procedures and medications.

Antibiotics used in dentistry

Penicillin: A common class of antibiotic with minor side effects that treats a broad range of bacterial infections

Amoxicillin and ampicillin: Antibiotics in the penicillin family that treat a greater variety of infections

Metronidazole: An antibiotic with antimicrobial properties that is regularly used to treat acute ulcerative gingivitis and is frequently used in conjunction with penicillin

Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.

Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.

Appropriate use criteria for the management of patients with orthopaedic implants undergoing dental procedures. Adopted by American Academy of Orthopaedic Surgeons Board of Directors and American Dental Association Council on Scientific Affairs – 2016. http://www.aaos.org/poiudpauc Accessed July 2018.